Cranial Injury in Resource-Limited Environments: An Evidence-Based Systematic Review of Approaches to Cerebrospinal Fluid Leak Management

Introduction: This study explores Cerebrospinal Fluid (CSF) leak diagnosis and management in Low- and Middle-Income Countries (LMICs).

Methods: A systematic review of the literature using PubMed, Google Scholar, and Web of Science electronic databases was completed according to the PRISMA guidelines to highlight articles discussing patient characteristics, management and outcomes related to CSF leaks in LMICs.

Results: 19 articles including 12 retrospective/prospective studies (2636 patients), 3 case series (23 patients), and 4 comparative studies (944 patients) from 11 countries were included. CT scans (10 retrospectives, 15 case, and 1 comparative) and MRI (6 retrospectives, 11 case, and 2 comparative) were indicated as the most used diagnostic method. Conservative management consisting primarily of antibiotics (7 retrospectives, 2 case, and 1 comparative) and lumbar drains (5 retrospectives, 9 case, and 1 comparative) aimed to prevent complications, reduce the need for secondary management, and enhance patient recovery. While multiple surgical techniques were used, the endoscopic endonasal technique, which had a CSF complication rate ranging from 0.00-22.00%, was the most frequently implemented (6 retrospectives, 22 case, and 3 comparative) in the LMIC’s: India, Egypt, China, Ivory Coast, Israel, Malaysia, Thailand, and Singapore. Comparatively, microscopic endonasal surgery had one study report in China, W85/592 patients (17.93%), with postoperative CSF leaks. Overall, the proportion of successful closures across all studies remained high, with the highest rate of complications observed being 19.64%. Further, acellular dermal matrix and turbinate flaps were shown to have similar repair rates in management of CSF rhinorrhea (95.23% and 96.00% respectively). Additionally, porcine-derived fibrin sealant improved successful repairs (49.21% to 97.81%) in craniotomies.

Conclusion : This study highlights advancements in the diagnosis, treatment, and management of CSF leaks patients in LMICs. Notably, the widespread adoption of endoscopic endonasal technique is notable as an advancement beyond microscope use.